St. Catherine University SOPHIA
Master of Social Work Clinical Research Papers School of Social Work
5-2016
Social Workers’ Duty to Report Dangers via Social Media: A Systematic Review
Katy Kolstad St. Catherine University, [email protected]
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Part of the Social Work Commons
Recommended Citation Kolstad, Katy. (2016). Social Workers’ Duty to Report Dangers via Social Media: A Systematic Review. Retrieved from Sophia, the St. Catherine University repository website: https://sophia.stkate.edu/ msw_papers/620
This Clinical research paper is brought to you for free and open access by the School of Social Work at SOPHIA. It has been accepted for inclusion in Master of Social Work Clinical Research Papers by an authorized administrator of SOPHIA. For more information, please contact [email protected]. Running head: SOCIAL WORKERS’ DUTY TO REPORT DANGERS
Social Workers’ Duty to Report Dangers via Social Media: A Systematic Review
by
Kaitlin R. Kolstad, B.A.
MSW Clinical Research Paper Proposal
Presented to the Faculty of the School of Social Work at Saint Catherine University and University of Saint Thomas Saint Paul, Minnesota in Partial fulfillment of the Requirements of the Degree of
Master of Social Work
Committee Members
Pa Der Vang, PhD, MSW, LICSW (Chair) Alyssa Rademacher, MSW, LICSW Jenna Senger, MSW, LICSW
The Clinical Research Project is a graduation requirement for MSW students at Saint Catherine University/University of Saint Thomas School of Social Work in Saint Paul, Minnesota and is conducted within a nine-month time frame to demonstrate facility with basic social research methods. Students must independently conceptualize a research problem, formulate a research design that is approved by a research committee and the university Institutional Review Board, implement the project, and publicly present the findings of the study. This project is neither a Master’s Thesis nor Dissertation. SOCIAL WORKERS’ DUTY TO REPORT DANGERS 2
Abstract
This systematic review aimed to evaluate social workers’ obligations to report suicidal or homicidal posts on social media. Inclusion and exclusion criteria were developed and multiple databases were searched for relevant literature. Of the literature searched, 26 articles were of use to the study. Based on the findings, there was a lack of concrete information regarding social workers obligations and mandated reporting guidelines of internet activity. The topic has not been studied to the degree that was required by this study. Current statutes and regulations would need to be updated to address the issue of social media use and suicide/homicide risk. More policies need to be developed in order to help those with mental illnesses that are a danger to themselves or others and it would work to help social workers provide comprehensive treatment for clients.
SOCIAL WORKERS’ DUTY TO REPORT DANGERS 3
Acknowledgements Woah. Not sure how I got here, but I am sure that I would not have stood a chance if it was not for some pretty amazing people. The support system of my mom and sister are the ones who believed in me when days seemed longer than I could handle. I could never put into words how much I love and appreciate them. To my boyfriend, John, who dealt with my lack of energy, late night ‘vent sessions’, and all the emotions that grad school elicits from you: I am forever grateful for your love and support through these wonderful and crazy three years. To the friends who I did not get to see on a regular basis because of deadlines and internship responsibilities: thank-you from the bottom of my heart and we should get together soon! And last, but certainly not least, I am eternally grateful to my research committee that helped me develop, revise, and critique my research into something that I can be proud to put my name on. I thank everyone who was involved on this journey as you all have helped change my life in ways I never knew possible. Thank-you
SOCIAL WORKERS’ DUTY TO REPORT DANGERS 4
Table of Contents Abstract ...... 2 Acknowledgements ...... 3 Mandated Reporting as Cornerstone of Social Work Practice ...... 6 Social Networking Sites and Danger-To-Self/Others Posts ...... 7 Hoax or Crisis?...... 8 Mandated Reporting and Danger to Self/Others ...... 10 Conceptual Framework ...... 12 Crisis Intervention ...... 12 Social Learning Theory ...... 13 Methods ...... 14 Research Purpose/Design ...... 14 Types of Studies ...... 15 Search Strategy ...... 15 Review Procedures ...... 16 Data Analysis Plan ...... 18 Table 1. Included Articles ...... 19 Results ...... 23 Thematic Analysis ...... 24 Discussion ...... 36 Lack of Response to Posts ...... 36 Lack of Professional Guidelines...... 37 Missed Posts ...... 38 Legal Issues ...... 39 Ethical Issues ...... 39 Limitations ...... 40 Further Research and Implications ...... 42 References ...... 44 Appendix A: Included Articles and Summary ...... 50
SOCIAL WORKERS’ DUTY TO REPORT DANGERS 5
Introduction & Literature Review
Technology is developing faster than anyone would like to admit. This issue has plagued schools, governments, medical settings, and is now impacting social work. In a time where there is a desire to be “plugged-in” at all times for fear of missing out on the hottest gossip, one begins to wonder how this technology will help or hinder mandated reporters. People are reaching out for help on social networking sites (SNS) more than ever with suicidal or homicidal behavior/actions. What has to happen for social workers to step in?
Social networking sites (SNS) and social media websites like Facebook,
Instagram, MySpace, Tumblr, SnapChat, and Twitter are becoming some of the most popular outlets for expressing oneself. With the ability to virtually express yourself, many posts can get lost in translation. This is creating a dilemma for social workers, who are mandated reporters, because in situations where they would otherwise report being a
‘danger to self or others’, this is not the case when technology is involved. When suicidal or homicidal intent is referenced on social media it does not include ideations for suicide and/or homicide. How are these situations handled? This question remains unanswered.
Neither legislature nor agency policies have caught up to technology.
This begs the question: How do we keep people safe? Through a systematic review, the obligations of social workers to report ‘danger-to-self/others’ situations posted via SNS will be reviewed and the available literature will be examined in order to gain insight into developing best practices for social workers in the age of technology.
SOCIAL WORKERS’ DUTY TO REPORT DANGERS 6
Mandated Reporting as Cornerstone of Social Work Practice A mandated reporter is someone who is obligated by law to report suspicions of child abuse and/or neglect, and, depending on the state, elder/vulnerable adult abuse as well (Krase, 2013). In Minnesota, there are statutes that require reporting on the maltreatment of minors, as well as vulnerable adults (Revisor of Statutes, n.d.). It may be thought that social workers are always reporters, but in 32 states, including Minnesota, one is only considered a mandated reporter when in their professional role. In other words, ‘wearing their social worker cap’ (Krase, 2013; Lau, K., Krase, K., & Morse, R.
H., 2009; Revisor, n.d.). In the event that there is a suspicion of abuse or neglect and one is not in their professional role, a report can be made, but that person is not obligated to do so (Krase, 2013; Lau, K., Krase, K., & Morse, R. H., 2009; Revisor, n.d.).
Mandated reporting is a career requirement as a social worker which may prevent people from mental and/or physical harm (Krase, 2013; Lau, K., Krase, K., & Morse, R.
H., 2009). Mandated reporters come from all professions. The Minnesota Office of the
Revisor Statute 626.556; Subdivision 3 defines a mandated reporter as: “…A professional or professional’s delegate who is engaged in the practice of healing arts, social services, hospital administration, psychological or psychiatric treatment, child care, education, correctional supervision, probation and correctional services, or law enforcement.”
Not only is social workers’ duty to report outlined by the Minnesota Revisor and the Board of Social Work, but it is also present in the National Association of Social
Workers (NASW) Code of Ethics (2008). The Code of Ethics states that:
Social workers’ primary responsibility is to promote the well-being of
clients. In general, clients’ interests are primary. However, social workers’ SOCIAL WORKERS’ DUTY TO REPORT DANGERS 7
responsibility to the larger society or specific legal obligations may, on
limited occasions, supersede the loyalty owed clients, and clients should
be so advised. Examples include when a social worker is required by law
to report that a client has abused a child or has threatened to harm
themselves or others. (Section 1.01; under ‘Social Workers Ethical
Responsibility to Clients’)
For mandated reporters it may seem commonplace to report instances where the injuries or accusations are observed or leave physical marks behind. What about a danger to self or others? This topic is placed under the child maltreatment umbrella, but what happens when there is a danger to self or others ‘threat’ that is posted via social media
(Broner, Embry, Gremminger, Batts, & Ashley, 2013)? Unfortunately, it is unclear whether there are regulations in place to deal with the rise of technology and mandated reporting standards. How effective is this for social work practice?
Social Networking Sites and Danger-To-Self/Others Posts Shah (2010) examined the link between social media (Internet) use and suicide rates. Shah (2010) found that the more a user is ‘online’ the more likely they are to commit suicide. This study allows researchers to question the content of the social media that users are on and how they use it. Luxton, June, and Fairall (2012) highlighted that some internet users have a high amount of social networking time which puts them at a greater risk to run across posts focusing on being a danger to self or others. High- quantity social media users may have a tendency to self-isolate which may suggest a greater prevalence for posts that lead to being a danger to self/others indicating a more troubling issue which needs immediate attention. SOCIAL WORKERS’ DUTY TO REPORT DANGERS 8
Magazines, including Time, have published articles regarding social networking sites (SNS) and danger-to-self/others postings. It might be assumed that any completed suicidal incident was preceded by a post or note. This is not typical and the posts have often gone unnoticed. Time Magazine (2014) published an article highlighting a situation where a teenage boy committed suicide after inquiring about the best methods to complete suicide on a popular forum (Dickey, 2014). This incident went unreported by another member of the message board and by the website itself (Dickey, 2014). In a different, but related situation, another website had repeatedly allowed suicidal/homicidal images from members (of the website) to be posted even after the website promised to ban the images (Simon, 2014). In this situation the posts did precede the suicidal or homicidal act (Simon, 2014).
Other media outlets have touted the positive uses for social media and SNS.
Psychology Today (2009) published an article regarding suicidal/homicidal issues and finding hope and support on social media. It outlined that more and more people, young adults mostly, are taking to social media and SNS to seek out help (Sandler, 2009; Social
Media Saves Suicides, 2013). Mental health resources have also used sites like Facebook and Twitter to raise awareness around suicidal issues which may have prompted some young adults to reach out (Sandler, 2009; Social Media Saves Suicide, 2013). Some help is sought by young adults on social media, but a large amount express their torment with
SNS posts.
Hoax or Crisis? It is not uncommon to ‘keep scrolling’ through a preferred SNS to find an interesting post to read, but how many of those posts that go unnoticed contain SOCIAL WORKERS’ DUTY TO REPORT DANGERS 9 potentially deadly information? Mandrusiak et al. (2006) evaluated 200 websites to look for warning signs of suicide. Of those websites, 3,266 warning signs were found on the websites searched and 42 percent of them contained direct suicidal threats (Mandrusiak et al., 2006). It is unknown as to how many direct suicidal threats were acted on or whether posts containing mental health concerns were noticed (Mandrusiak et al., 2006).
When a particularly dramatic post appears on a SNS news feed, it may be met with an eye-roll, snide comment about how ‘dramatic’ that person is, or that they are having a ‘bad day’. Cash, Thelwall, Peck, Ferrell, and Bridge (2013) performed a content analysis of MySpace (a specific SNS geared toward adolescents) where researchers evaluated suicidal statements being posted. Of the statements found, many of them referred to ‘risky’ behaviors and suicidal intentions (Cash, Thelwall, Peck, Ferrell,
& Bridge, 2013). This may be part of the reason why SNS users scroll past potential suicidal postings because there is a lack of context. How many suicidal social media users need be in danger before more posts get noticed?
Facebook seems to be at the forefront of SNS activity recently, but with greater consumer use comes the possibility for increased demonstration of problems via postings.
More people, especially adolescents, are using SNS’s for posting the minutiae of their lives for all of their ‘friends’ to see. Masuda, Kurahashi, and Onari (2013) found this to be quite interesting and aimed to look at how the number of Facebook ‘friends’ affected the number of suicidal postings in adolescent users. Since adolescents spend some time each day on their SNS of choice, it might be concluded that their posts are a semi-true reflection of their real life experiences (Masuda, Kurahashi, & Onari, 2013). It was found that, across the sample, the more ‘friends’ a Facebook user had, the fewer number of SOCIAL WORKERS’ DUTY TO REPORT DANGERS 10 suicidal postings there were (Masuda, Kurahashi, & Onari, 2013). A possible explanation for this is the more ‘friends’ one has on Facebook (or another SNS), the higher likelihood that the suicidal posting will be noticed. It is not known for sure, but many suicidal postings are going unnoticed and may encourage social media users to take their own lives.
On social media sites, like forums, there are posts regarding best suicide practices.
These posts seem to go unnoticed as well. Time Magazine (2014) discussed this very issue and spoke of a young teen who ended up completing his suicide plan after ‘getting ideas’ from an online social media forum. There were numerous responses to this teen’s questions on the website, and it went unreported (Dickey, 2014). Sometimes, a lack of action may be due to users believing that someone else will take care of it; a kind of
‘virtual bystander effect’ and it may be having negative effects on social media users
(Dickey, 2014). It may also be assumed, when seeing a suicidal posting on a SNS, another user might see it as an ‘attention-seeking’ behavior or someone being ‘dramatic’ when, in reality, it may be a cry for help.
Mandated Reporting and Danger to Self/Others It is suggested that environmental, family dynamics, or adverse events can be indicative of potential child maltreatment (Broner, Embry, Gremminger, Batts, & Ashley,
2013). Child maltreatment and child abuse is what ‘danger to self/others’ is categorized as under the Minnesota Statutes (Revisor, n.d.) The Office of the Minnesota Revisor
(n.d.) Statute 626.556 views ‘being a danger to self/others’ as having a mental injury (or experiencing mental illness symptoms). Other factors include behavioral health issues and ‘risky’ behaviors such as promiscuity, substance use, or a history of abuse. Also, any SOCIAL WORKERS’ DUTY TO REPORT DANGERS 11 activity that may potentially cause mental injury could also be considered child maltreatment and give professionals a reason to report (Revisor, n.d.). But with the explosion of the internet and Social Networking Sites (SNS), laws and regulations have not been able to keep up with professional practice standards.
In an article by Tonn (2006), it was suggested that there is a need for teachers to have access to SNS in order to monitor students’ mental health via postings. This article was presented during a time when, after multiple school shootings, a need arose for school teachers to be able to see the virtual lives of students in order to protect them. For example, Eric Harris (a gunman in Columbine School Shooting of 1999) and Jeff Weise
(2005 Red Lake High School Shooting gunman) both posted violent images and status updates via social media in the days and months leading up to their respective shootings
(Tonn, 2006). Tonn (2006) found that there is a need for more monitoring in order to promote a safe environment, online and offline.
Promoting safety of clients over SNS is an issue that plagues mandated reporters, social workers specifically. As a review of the literature has shown, many people will post troubling images and/or posts that indicate a danger to self and/or others. Is this an issue for mandated reporting standards? Lehavot, Ben-Zeev, and Neville (2012) analyzed how social media can cause ethical issues with clients. It was found that an unusual paradox emerges when the social worker needs to stay professional, but there is also a chance of negligence if an issue is not reported (Lehavot, Ben-Zeev & Neville, 2012).
The ‘duty to warn/report’ that social workers often experience has not been thought to cover SNS, but there is a need for it. SOCIAL WORKERS’ DUTY TO REPORT DANGERS 12
As social work emerges into the Digital Age, it is met with an outdated way of handling troubling posts via SNS which creates a barrier to successful treatment for many consumers (Reamer, 2013). Reamer (2013) specifically studied the effect that the internet and unlimited access has on treatment and social work practice; especially with clients who are a danger to self and/or others. It was explained that users can press a
Report Suicidal Content button on Facebook and have the posts owner connected to resources that may help them (Reamer, 2013). However, this button is hard to find and only provides the user with phone numbers to call and a small form to fill out. The situation is the same for SnapChat, Instagram, and Twitter. This may be an effective way to help people if another user sees their troubling post, but how do social workers fit into this equation? Although there is an obligation to report suspicious first-hand observations of abuse or neglect, what is the obligation to report observations of abuse or neglect via social media in the form of posts referencing a danger to self and/or others?
Conceptual Framework Crisis Intervention How the research question is evaluated depends on the lens through which it is seen. In order to better evaluate whether or not social workers have an obligation to report social media posts regarding danger to self/others, there needs to be a conceptual framework in place. One relevant conceptual framework is Crisis Intervention. There needs to be more crisis intervention techniques in place so there is a greater sense of urgency to notice concerning posts on social networking sites (SNS). Time Magazine
(Dickey, 2014) highlighted a situation where a student posted multiple times that they wanted the ‘best way’ to kill themselves. Unfortunately, other forum users answered SOCIAL WORKERS’ DUTY TO REPORT DANGERS 13 with ideas for suicide completion (Dickey, 2014). This was not reported by the website’s owners nor was it flagged by other users (Dickey, 2014). This situation is becoming more common in society than some may believe. This graphically illustrates the need for more crisis intervention techniques that apply to technology and posts on social media pertaining to being a danger to self or others.
A change in the reporting guidelines for mandated reporters (social workers) would need to happen in order for reports to be made from observations on social media.
This would allow more reports to be made and, potentially, save lives. Not only is it important for social workers to be able to report danger to self or others via social media, it is also equally imperative that websites and users be more vigilant by looking for concerning signs. Looking through a Crisis Intervention lens allows social workers the ability to help more people by keeping up to date with the Digital Age so distressed individuals are not overlooked as they use social media to express their internal pain.
Social Learning Theory It is important to delve into why distressing posts regarding a danger to self or others are going unnoticed on Social Networking Sites (SNS). One way to evaluate this issue is to look at Social Learning Theory. Social Learning Theory suggests that human behavior is learned from interacting with the environment around them (Bandura, 1977).
This theory illustrates that almost all of the social skills that are learned are done so through observation of others’ behavior and the consequences associated with it
(Bandura, 1977). Knowing about Social Learning Theory can explain why so many social media posts regarding being a danger to self/others are going unnoticed. It may also outline how learned behaviors that are unconsciously observed by the brain may be SOCIAL WORKERS’ DUTY TO REPORT DANGERS 14 used as proof for how to act (Bandura, 1977). All of this information is gathered from our environment and encoded into something meaningful for use in future similar situations.
Information gathered from the environment creates an issue for those SNS users that are attempting to express their discomfort with life in the digital world. Not only are these users potentially feeling lost and isolated, but by not having anyone respond to their cries for help can have a detrimental effect on cognition. It may seem like they are “not important” if nobody cares enough to comment on their post. This is, unfortunately, how scenarios play out on social media consistently throughout the day. Evaluating the problem of ignored social media posts through the lens of Social Learning Theory could allow society to reflect inward and make a change to start noticing distress and take action.
Methods Research Purpose/Design The purpose of this systematic review was to examine the question: what are social workers’ obligations to report ‘danger to self or others’ posts on social media?
For the purpose of this study, the terms ‘social networking sites’ (SNS) and
‘social media’ were used interchangeably in order to increase the amount of relevant literature that met selection criteria. SNS and social media are websites and applications that allow users to post and/or share content to engage in social networking (Oxford
Dictionary, 2015). The sites that were most prevalent in research included Facebook,
Twitter, Instagram, Tumblr, and MySpace (Cash, Thelwall, Peck, Ferrell, & Bridge,
2013; Lehavot, Ben-Zeev & Neville, 2012). This review evaluated posts on social media SOCIAL WORKERS’ DUTY TO REPORT DANGERS 15 sites that reference being a danger to self or others. Posts that include suicidal/homicidal ideation, just thinking about harming yourself and/or others, were not included because social workers are not obligated to report ideations per Minnesota Statute. This helped to exclude content regarding ideation of harm versus actual intent to harm.
Types of Studies Many studies were considered in determining social workers obligations as mandated reporters concerning social media posts where the user being a danger to themselves or others. These include: case studies, empirically based studies, conference proceeding, gray literature, qualitative and quantitative studies, and other systematic literature reviews. The focus of this study was to find themes throughout the literature that provides guidance for social workers in their mandated reporter role. This was thought to be demonstrated through data regarding the amount of social media posts that spoke to danger to self/others intentions, ethical and reporting guidelines for social work clinicians.
Search Strategy In an initial search of academic journals and online databases including
PsychINFO, SocINDEX, Acadamic Search Premier, and EBSCO Megafile, there was only a handful of articles that mentioned social media and social workers, but not within the scope of this study. Most of the studies focused on ethical issues around being
‘friends on Facebook’ with clients. In order to better understand the amount of literature available regarding the research question, a search for specificity and sensitivity was performed. A search for specificity allows researchers to narrow down the research focus in order to yield a higher number of relevant articles. Although the yield for specificity searches may be high, researchers run the risk of missing relevant articles due to the SOCIAL WORKERS’ DUTY TO REPORT DANGERS 16 narrow focus of the search terms. A sensitivity search was also performed to help retrieve a high number of relevant studies, but this may also yield a high number of irrelevant studies (if there is high sensitivity). By running sensitivity and specificity searches, it allowed for a better understanding of the available literature, helped to narrow down search terms, and even assisted in developing inclusion and exclusion criteria. Both searches were conducted and considered an integral part of this study.
Review Procedures Articles, found on specified databases, which are peer-reviewed and available in full-text, or not, were considered. If the desired article was not available in full-text through the databases, then they were requested by an inter-library loan service called
Illiad. This allowed for a larger amount of relevant articles to be found and used for this study. Due to an issue that there are not any policies around the connection between mandated reporting and social media posts, any relevant gray literature found via Google
Scholar was also included in the literature review (these are not required to be peer- reviewed) (Gelfand & Lin, 2013). Gray literature was helpful to this study because it allowed access to information that is relevant to the research which may not have been published to a peer-reviewed journal yet (Schmucker, Bluemle, Briel, Portalupi, 2013).
The resources used were researched from October 2015 to January 2016. In order to address any validity issues, the aforementioned resource qualifications were put in place.
Also, the following social media sites were contacted for attempted inclusion in this study: Facebook, SnapChat, Instagram, MySpace, and Twitter. The social media sites were asked what their policy/policies and responses regarding suicidal and/or homicidal posts. SOCIAL WORKERS’ DUTY TO REPORT DANGERS 17
Inclusion Criteria. In the databases of PsycINFO, SocINDEX, EBSCO
MegaFile, and Academic Search Premier, a search was run using a combination of terms;
“Social networking site(s)” or “social media”, AND “suicide”, “suicidal intent”, “self- harm”, or “danger to self/others”. Another search in these same databases was ran with the terms: “mandated reporter”, “mandated reporting”, “duty to warn” or “duty to report”
AND “social worker(s)” AND “suicide”, “suicidal intent”, “self-harm”, or “danger to self/others”. Once the search was done, specification was established by selecting the term(s) that seemed to produce the most relevant literature from the searches. A search for gray literature was also performed in order to find relevant magazine articles and other published items that was beneficial to include in the review. The same search terms were used in the other databases chosen in order to keep consistency across literature types and databases.
The focus of this research was the obligations of social workers to report dangerous activity via social media posts, therefore articles that were included on this topic did not include all three categories of search terms. In general there was a lack of information about this topic which allowed for parsing out the research question to find articles that fit each part. Themes were used to tie the parts together. For example, the
“social worker(s) having an obligation to report” and the “danger to self/others posts via social media” are the two parts that were brought together with themes found in studies.
Exclusion Criteria. Any articles that reference suicidal ideation were excluded from research because social workers typically do not report on suicidal ideation alone.
There needs to be more of an intent or a plan in place to cause a report to be made (Krase,
2013; Lau, K., Krase, K., & Morse, R. H., 2009). Also, any articles that reference SOCIAL WORKERS’ DUTY TO REPORT DANGERS 18 teachers as mandated reporters were also excluded because this study focused on social workers as mandated reporters. Articles were required to be in English in order for researchers to comprehend the information and use it in the appropriate manner.
Inclusion and exclusion decisions were made based on the titles and abstracts of articles and gray literature found. After data collection was completed, a table was set up for a complete list of included articles and gray literature. A more detailed list of resources used in review, with short summary, is located in Appendix A.
Data Analysis Plan Using the databases of PsycINFO, SocINDEX, Academic Search Premier, and
EBSCO MegaFile a search was run with the selected terms, inclusion criteria, and exclusion criteria laid out above. A search of the gray literature by using Google Scholar was utilized as well to find relevant resources that are not peer-reviewed. From the results of the search, the qualifying resources were thoroughly reviewed for themes. This thematic analysis comprised the findings of the study. The themes are outlined and discussed based on their relevance to the study and what was able to be deduced from them in order to inform the study’s research question.
SOCIAL WORKERS’ DUTY TO REPORT DANGERS 19
Table 1. Included Articles Database Title Author(s) Keywords Used To Locate
Academic Search “Girl’s suicide Alvarez, L. (2013) “Social Premier points to rise in networking site” apps used by & “suicide” cyberbullies.”
“Suicide and the Biddle, L., Donovan, “social media” & Internet.” J., Hawton, K., & “suicide” Kapur, N. (2008)
EBSCO MegaFile “Facebook suicide International “social prevention service: Business Times networking site” Help for users or (2011) & “suicide” invasion of privacy?”
“Questions about Hussey, K., & “social media” & missed signs after Leland, J. (2013) “suicide” 15-year-old boy’s suicide in Greenwich.”
“US woman, International “social Cynthia Lee, posts Business Times networking site” disturbing suicide (2012) & “suicide” note on Facebook.”
Google Scholar “Cybersuicide: Alao, A.O., “social media” & (Grey Literature) Review of the role Soderberg, M., Pohl, “suicide” of internet on E. & Alao, A.L. suicide.” (2006)
“Responses to a Fu, K., Cheng, Q., “social media” & self-presented Wong, P., & Yip, P. “suicide” suicide attempt in (2013) social media.” SOCIAL WORKERS’ DUTY TO REPORT DANGERS 20
“Suicide Ruder, T.D. Hatch, “social announcement on G.M., Ampanozi, G., networking site” Facebook.” Thali, M.J., & & “suicide” Fischer, N. (2011)
“Suicide detection Varathan, K.D., & “social media” & system based on Talib, N. (2014) “suicide” Twitter.”
“Suicide and social Robinson, J., “social media” & media.” Rodrigues, M., “suicide” Fisher, S., & Herman, H. (2014)
“The internet and Tam, J., Tang, W.S., “social suicide: A double- & Fernando, D.J.S. networking site” edged tool.” (2007) & “suicide”
PsycInfo “Adolescent suicide Cash, S. J., Thelwall, “social media” & statements on M., Peck, S. N., “suicide” MySpace.” Ferrell, J. Z., & Bridge, J. A. (2013)
“Ethical Lehavot, K., Ben- “social media” & considerations and Zeev, D., & Neville, “suicide” social media: A R. E. (2012) case of suicidal postings on Facebook.”
“Similarities and Belfort, E.L., “social differences among Mezzacappa, E., & networking site” adolescents who Ginnis, K. (2012) & “suicide” communicate suicidality to others via electronic versus other means: A pilot study.”
“Social media and Robinson, J., Cox, “social media” & suicide prevention: G., Bailey, E., “suicide” Hetrick, S., Rodrigues, M., SOCIAL WORKERS’ DUTY TO REPORT DANGERS 21
a systematic Fisher, S., & review.” Herman, H. (2015)
“Suicide on Ahuja, A.K., “social media” & Facebook.” Biesaga, K., Sudak, “suicide” D.M., Draper, J., & Womble, A. (2014)
“The representation Westerlund, M., “social of suicide on the Hadlaczky, G., & networking site” internet: Wasserman, D. & “suicide” Implications for (2012) clinicians.”
“Understanding Baker, D., & “social self-harm and Fortune, S. (2008) networking site” suicide websites.” & “self-harm”
SocIndex w/ Full “Duty to warn, duty Granich, S. (2012) “duty to warn” & Text to protect.” “social worker(s)” & “self-harm”
“Social media and Luxton, I. D., June, “social media” & suicide: A public J. D., & Fairall, J. “suicide” health perspective.” M. (2012)
“The representation Zdanow, C., & “social of self-injury and Wright, B. (2012) networking site” suicide on emo & “suicide”; social networking “social media” & groups.” “suicide”
Articles Found “Making the Tough Krase, K.S. (2013). From Literature Through Other Call: Social Review. Means Workers as Mandated Reporters.”
“Pro Self-Harm and Boyd, D., Ryan, J., Found in Cash et the Visibility of Leavitt, A. (2010). al (2013) Youth-Generated reference section. SOCIAL WORKERS’ DUTY TO REPORT DANGERS 22
Problematic Content.”
“Social Work in a Reamer, F.G. From Literature Digital Age: Ethical (2013). Reivew and Risk Management Challenges.”
“Tarasoff and the Appelbaum, P.S. Found in Granich Clinician: Problems (1985). (2013) reference in Fulfilling the section. Duty to Protect.”
“The Antisocial Dickey, J. (2014). From Literature Network” Reivew.
SOCIAL WORKERS’ DUTY TO REPORT DANGERS 23
Results The purpose of this systematic review was to explore the question: What are social workers’ obligations to report suicidal/homicidal behavior via social media posts?
With the data collected via the inclusion and exclusion criteria the research question was not supported by the literature. This was demonstrated through a lack of evidence from the literature outlining what the specific obligations of social workers are regarding mandated reporting of online suicidal or homicidal threats. Literature found, supported the themes outlined in the Literature Review, but failed to concretely answer the research question. However, based on the relevant literature found, various inferences can be made regarding social workers’ obligations; this will be outlined in the discussion section.
Using the databases of Academic Search Premier, EBSCO MegaFile, Google
Scholar (gray literature), PsycInfo, and SocIndex with Full Text, as well as working within the inclusion and exclusion criteria previously outlined above; 26 peer-reviewed articles, dissertations, case discussions, and conference proceedings met criteria and were reviewed. Of the articles found, nine (35 percent) were focused on the content of social media sites being used for suicidal purposes and how those articles were affecting users.
Only one article (4 percent) addressed social media and suicide as a society issue, while
23 percent (n=6) of articles focused on clinician’s duty of care for clients who use social media for suicidal purposes. The rest of the articles (n=10) looked at how social media and suicide are linked, and what needs to be done about it; the ages of users were not discussed. SOCIAL WORKERS’ DUTY TO REPORT DANGERS 24
Broadly, of the 26 articles found, 13 (50 percent) focused on how social media use and suicide are related with discussion surrounding what actions need to be taken to help. The other 50 percent (n=13) looked at what clinicians are supposed to be doing/reporting in regards to suicide and, specifically, suicide on social media. The articles found did not focus specifically on one gender or the other. It seemed to be pretty even across the articles found.
Research articles made up 35 percent (n=9) of the included articles. Of these nine articles, two were systematic reviews (22 percent), one (11 percent) was a qualitative study, two (22 percent) were quantitative studies with data recovered from social media websites, and 4 (44 percent) were exploratory in nature where the focus was to analyze websites and explore the users posts/content. The other 65 percent (n=17) of the articles found and reviewed included: one editorial, three case discussions, one conference presentation, and twelve were general articles (including magazine/newspaper articles).
As stated earlier, multiple social media sites were contacted via email for their policies regarding suicidal/homicidal posts (Facebook, Twitter, SnapChat, Instagram, and
MySpace) and there were not any responses given even after multiple attempts.
Thematic Analysis Through analysis of the literature, five interrelated themes emerged from this systematic review around what obligations of social workers are when reporting suicidal and homicidal threats via social media. Unfortunately, none of the themes that emerged from the literature answered the research question. The themes that emerged provide evidence as to why this topic needs to be further addressed for clinicians. The themes address why suicide on social media is a problem and what the issues surrounding SOCIAL WORKERS’ DUTY TO REPORT DANGERS 25 mandated reporting for social workers are. These themes include: 1) there is a lack of response to social media posts; 2) there is a lack of professional guidelines and mandated reporting guidelines; 3) suicidal posts are missed by users; 4) there are legal issues; 5) there are ethical issues and duty of care considerations.
There is a lack of response to suicidal posts on social media. A fair amount of the articles found for review focused mainly on suicide and how the internet impacts it.
Specifically, Biddle, Donovan, Hawton & Kapur (2008) evaluated what was happening when social media users posted suicide notes online and how other users reacted. It seemed like users of suicide websites were often encouraging those who post suicide notes to complete their plans (Biddle, Donovan, Hawton, & Kapur, 2008). Suicide was offered as a sort of ‘problem-solving’ strategy for those who were struggling with mental illness and/or bullying. Initially, suicide notes were noted to be ambivalent, but more users from suicide websites began encouraging other suicidal members and their resolve strengthened which resulted in more completed suicides (Biddle, Donovan, Hawton, &
Kapur, 2008).
There is a lack of response to suicidal posts on social media most likely due to other users believing that the suicidal user is ‘dramatic’ or ‘having a bad day’, but in other cases, users will do nothing to help this struggling person except antagonize them into completing suicide or engaging in self-injurious behaviors (Zdanow & Wright,
2012). According to Zdanow & Wright (2012), “romanticizing suicide and suicidal behaviours have become more accessible and vivid” (p. 82). This statement illustrates that it is becoming far too common for users to find suicide as a viable option for treating their life struggles; especially when other social media users are encouraging suicidal SOCIAL WORKERS’ DUTY TO REPORT DANGERS 26 thinking and behaviors. Zdanow & Wright (2012) discuss the need for some users to antagonize a suicidal user. It is outlined that there is a strong need for communication, to escape from their own issues, or even for a personal perversion for voyeurism into social media users’ lives.
International Business Times ran an article (2011, December 13) that spoke to the process of ‘reporting’ suicidal posts on a social media site. It was stated that all posts need to be ‘flagged’ or manually reported through a separate part of the social media webpage. Once this ‘reporting’ is done, the suicidal user will be sent an email with a phone number to a suicide prevention line (International Business Times, 2011). It takes multiple steps in order to report a suicidal post and social media users might not want to go through those steps. International Business Times (2011, December 13) writes about multiple stories that outline how adolescents have posted information regarding suicide that was not acted on by the social media site or another user, and that user ended up completing suicide. The process of reporting on a social media site indicates that there is a lack of urgency when it comes to the lives of its users.
The involvement of a parent figure is not enough to elicit a response from social media sites. The New York Times (2013, September 14) shed light on the lack of response to social media posts by interviewing a mother who lost her daughter to suicide.
It seemed like all of the users’ ‘problems’ were caused by social media and the fact that the adolescent who was struggling was engaging with users on social media who were bullying to the point of suicide (Alvarez, 2013). Even where there are blatant examples of suicidal posts on social media, other users are failing to mention those concerning posts which only works to negatively affect the problem many people are experiencing while SOCIAL WORKERS’ DUTY TO REPORT DANGERS 27 using social media. There is a lack of response to social media posts that have suicidal messages even by the websites themselves. Dickey (2014) with Time Magazine outlines how many messages from an adolescent were posted online referencing suicide and there was a severe lack of response. The social media website with message boards was ordered to take down the content, but has not been as of yet (Dickey, 2014).
Lack of professional and mandated reporting guidelines. This topic is influencing psychiatry due to the internet widespread source of information and communication. It seems that there is a lack of procedure for how to incorporate psychiatry into the online world (specifically, social media) (Alao, Soderberg, Pohl, &
Alao, 2006). Unfortunately, there are sites that will encourage someone to complete suicide, but there are just as many social media sites that are working to prevent suicide
(Alao, Soderberg, Pohl, & Alao, 2006). As outlined in Fu, Cheng, Wong & Yip (2013), social media allows for “uninhibited communication and selective self-presentation of undesirable behavior” (p. 406). This selective self-preservation is allowing suicidal users to communicate with ambiguity where it might be difficult for a clinician to properly intervene. The use of social media with clients, or suicidal clients in particular, is allowing for wide diffusion of one’s thoughts and/ or behaviors which might be helpful when used as an early suicide identification tool (Fu, Cheng, Wong, & Yip, 2013). It is proposed that clinicians who work with suicidal, or even homicidal, clients explore their social media use to look for warning signs and to establish a referral system that is fast and effective for those users who are found to be actively suicidal (Fu, Cheng, Wong, &
Yip, 2013). SOCIAL WORKERS’ DUTY TO REPORT DANGERS 28
Suicide has been recognized as a public health problem and it is suggested that there be media guidelines in place for professionals to use (Tam, Tang, & Fernanado,
2007). Unfortunately, there is currently a lack of guidelines for professionals when it comes to internet-based activities (Tam, Tang, & Fernando, 2007). Even when social media turns into an online ‘therapy session’ by peers commenting on posts with encouraging words, this may cause the suicidal user to seek help outside of the professional circle (Belfort, Mezzacappa, & Ginnis, 2012). The way that some social media users are choosing to communicate their distress, and with whom, can exaggerate their desire to disclose to a professional, which makes it even harder for professionals to treat those people because of this barrier (Belfort, Mezzacappa, & Ginnis, 2012).
Websites even been seen as more accessible than professional mental health resources, but there is also a lack of appropriate responses on social media sites (as discussed earlier) (Baker & Fortune, 2008).
Professional literature has not covered the procedure for suicide notes posted on social media sites yet (Ruder et al, 2011). Due to the lack of professional guidelines that address problematic behaviors via social media, an opportunity is provided to other users of social media to take advantage of those at risk (Ruder et al, 2011). Even when discussing mandated reporting guidelines, there is a lack of information regarding social media/internet safety issues. It has been outlined that if a professional is a social worker, then they have to observe a problematic behavior, but only when they are in the role of their professional license (Krase, 2013). If a social worker is not in their professional role, then they are not required to make a report; at this point there could be a discussion SOCIAL WORKERS’ DUTY TO REPORT DANGERS 29 of negligence on the part of the social worker (Krase, 2013). This will be discussed further in an upcoming theme.
Professional guidelines already focus on the ‘duty to warn/duty to protect’ idea and it would only make sense that this be applied to social media users. This question of
‘duty to warn/duty to protect’ is one of the most common ones that clinicians have
(Appelbaum, 1985). Mandated reporting becomes a struggle for clinicians to make sure that they have enough evidence in order to make a report in the first place; professionals have been scolded because of a lack of evidence (Appelbaum, 1985). The lack of literature surrounding reporting guidelines has only served to confuse clinicians about their obligations to their clients (Appelbaum, 1985). Westerlund, Hadlaczky, &
Wasserman (2012) believe that it is a “very important task for clinicians to respond to the substantial amounts of pro-suicide messages on the internet and to continue to develop preventative strategies for individuals at risk for suicidal acts…” (p. 7). Establishing routines for clinicians is one way to greatly affect the impact of suicidal internet posts
(Westerlund, Hadlaczky, & Wasserman, 2012).
Many suicidal posts are missed by other users. One post on social media can reach, potentially, thousands of people within minutes. This is not limited to Facebook,
Twitter, Instagram, and Snapchat; there are other social media sites that are geared toward those struggling with mental illness (Baker & Fortune, 2008). Some social media sites are known as ‘suicide websites’ and specifically focus on how to best complete suicide. These websites are often ‘members only’ which only works to further alienate people who may be experiencing a significant amount of isolation and alienation already
(Baker & Fortune, 2008). This issue may increase the frequency of suicidal posts and SOCIAL WORKERS’ DUTY TO REPORT DANGERS 30 prevent people from seeing them when it is most important. If users of social media end up feeling more isolated from the larger society then there may be even more hesitation to seek professional help, which would only work to intensify their mental illness (Baker
& Fortune, 2008).
When using the social media site Twitter, users can ‘tweet’ at someone else by tagging them with “@theirusername” which then notifies that other user of a post when there were ‘mentioned’. ‘Tweeting’ creates another issue regarding social media, specifically that posts being missed by users. Suicidal users may ‘mention’ others in order to gain attention. With thousands of tweets being sent over the internet daily, when a user is specifically mentioned by another user, it does not guarantee that the tweet will be seen and, more importantly, acted upon (International Business Times, 2011).
Twitter has been the subject of a study by Varathan & Talib (2014) where a suicide detection system was developed and evaluated. When tested, news of a crime can be detected within 10 minutes after the incident, but it takes almost three hours for the news to report it (Varathan & Talib, 2014). Varathan & Talib (2014) highlight that a suicidal post can be seen as a “cry for help, and if the signs are recognized early, lives could be saved” (p. 785). By having a detection system, less suicidal/homicidal posts would be missed and it would only make sense to take advantage of Twitter’s speed and breadth so potentially life-threatening events can be addressed (Varathan & Talib, 2014).
To further emphasize this point, Varthan & Talib (2014) outline:
It is proven in many suicide cases in which the suicide victims had left behind
their feelings of hopelessness, talking about their intentions, or having no reasons SOCIAL WORKERS’ DUTY TO REPORT DANGERS 31
to live on Twitter before ending their life. But most of the time, their posts are not
taken seriously or unattended and leads to death (p.786).
The creation of a detection system that works with social media sites would allow for further monitoring of potentially dangerous posts. There are many examples of situations where kids have posted statements on social media that have ultimately preceded their death(s).
One example is of a young adolescent who repeatedly posted suicidal and
“goodbye” messages on Google Plus (another social media site somewhat similar to
Facebook). School officials failed to detect those posts (Hussey & Leland, 2013).
Regardless of the cause of suicidal posts on social media, many messages are missed which only reinforces one’s feelings of isolation and hopelessness if no one sees/notices their cry for help. International Business Times (2012, January 25) highlighted the story of another young person who committed suicide after putting a suicide note post on
Facebook. This person was reportedly struggling in multiple areas of life and coping with childhood issues (International Business Times, 2012). A final example of posts being missed on social media comes from the site Ask.fm where users can ask questions about anything. Specifically, this message board focused on suicide. One needs a username and password to access this part of the website. A young teenager consistently went on
Ask.fm to ask about suicide as well as his feelings of depression and hopelessness
(Dickey, 2014). Not only were his suicidal posts missed from mainstream society and those who may be able to report suspicious messages, there were people on Ask.fm who were encouraging the boy to take his own life (Dickey, 2014). When suicidal posts are missed on social media, it may allow dangerous situations to develop. More detection on SOCIAL WORKERS’ DUTY TO REPORT DANGERS 32 social media may help to “fix things”. Dickey (2014) believes that “the obligation to fix things does not rest with [the social media site]…it falls on parents, teachers… and society” (p.45).
There are legal ramifications if issues are not reported. As discussed above, limited visibility of posts may cause them to be missed, but this theme touches on a different issue where there are legal consequences if proper action is not taken to report suicidal behavior. This issue of limited visibility of some social media sites significantly decreases the opportunity to help those in need in a timely manner (Boyd, Ryan &
Leavitt, 2010). Currently if there is a suspected issue with suicidality (not on the internet because statutes in Minnesota do not address this) and there is a failure to report such behavior, then the clinician can have legal charges brought against them (Krase, 2013).
Boyd, Ryan, and Leavitt (2010) discuss, at length, that there is a lack of “formalized efforts by mental health practitioners and social services” (p. 29) to help prevent and/or monitor social media posts. They also go on to state that there is a need for proactive solutions, possibly in the form of a program that leverages the visibility of users’ social media content and mental health practitioners to help report issues (Boyd, Ryan &
Leavitt, 2010).
The principle of negligence is consistently spoken of in relation to mandated reporting. Levahot, Ben-Zeev, and Neville (2012) discuss:
If a clinician is alerted to possible dangerous behavior by a client (e.g harming
self or others)-either by information found online or by report from another
individual-failure to act may result in negligence and adverse consequences for SOCIAL WORKERS’ DUTY TO REPORT DANGERS 33
the client. Taking appropriate steps may constitute legal duty that was confirmed
in the 1976 case, Tarasoff v. Regents of the University of California, in which a
psychologist was held liable for failing to warn a woman that the psychologist’s
client disclosed plan to kill her in therapy (p. 343).
Legal literature suggests that it is of utmost importance for clinicians to evaluate their legal responsibility when encountering suicidal and/or homicidal information online
(Levahot, Ben-Zeev, & Neville, 2012). Adhering to mandated reporting guidelines is essential and in order to avoid legal ramifications, the use of social media for posting suicidal/homicidal information needs to be discussed in the informed consent with clients
(Levahot, Ben-Zeev, & Neville, 2012).
Studies have found that 50 percent of suicide attempters disclose plans to family and/or friends before the attempt (Beck, Steer, & Ranieri, 1988 as citied in Ahuja,
Biesaga, & Sudak, 2014). An idea posited by Ahuja, Biesaga, and Sudak (2014) is that more suicidal disclosures will be done through electronic means. The increase in electronic communication of suicidality might mean that more clinicians will be at risk for legal issues regarding reporting and negligence. Cash, Thelwell, Peck, Ferrell, and
Bridge (2013) cite Boyd, Ryan, and Leavitt (2010) when the issue of visibility is discussed because it can be used as a source of information where we can learn and engage with those on social media. If clinicians are able to engage more social media users, then the threat of legal negligence could potentially decrease when there is less uncertainty about whether or not report an issue. SOCIAL WORKERS’ DUTY TO REPORT DANGERS 34
Ethical issues with reporting of social media issues. There is often a question of whether or not content from social media should or can be censored for the safety of the users (Robinson, Rodrigues, Fisher, & Herman, 2014). There is also the question of whether online content can be used to track at-risk individuals in order to prevent serious issues from developing (Robinson, Rodrigues, Fisher, & Herman, 2014). However, censorship brings up issues of ethics and duty of care (Robinson, Rodrigues, Fisher, &
Herman, 2014). There is also some difficulty in intervening with people in online forums due to the anonymity of sites which makes it challenging to trace the users (Robinson,
Rodrigues, Fisher, & Herman, 2014).
Robinson et al. (2015) performed a systematic review studying social media sites that focused on suicide prevention in which they found that most sites were governed by ethical codes of conduct and controlled by volunteers with supervision experience. This is contrasted by what is typically found on pro-suicide websites that are mismanaged and dangerous to users. These sites have been shown to have issues with controlling users’ behaviors, accurately assessing emotional states of those online, and the ‘social contagion’ of suicide (Robinson et al, 2015). The ethical issues that exist in terms of duty of care as well as privacy and confidentiality pose challenges for clinicians who are unaware of the ways that people use social media (Robinson et al, 2015).
Granich (2012) states “protecting the well-being of homicidal and suicidal clients in the obligation of professional social workers” which is evidenced in the National
Association of Social Workers (NASW) Code of Ethics (p. 4). The use of supervision and consultation is key when working with issues of malpractice and ethics (Granich, SOCIAL WORKERS’ DUTY TO REPORT DANGERS 35
2012). When considering a potentially dangerous situation and whether or not to ethically address it, Appelbaum (1985) as cited in Granich (2012) speaks to a three-step process:
[First] gather relevant data to evaluate dangerousness and make a determination
based on this data, [second] once determining a situation to be dangerous, a
course of action must be taken, and [third] the therapist must implement this
decision (p. 6).
Considering the simplicity of the steps described above, social media could qualify as a situation where one could be deemed dangerous (to themselves or others) and help to avoid ethical issues for clinicians.
Another ethical issue that mental health professionals, as a whole, have to navigate is the ‘freedom of speech and expression’ concept that many who use social media. Luxton, June, and Fairall (2012) outlines that the internet is an open forum with very little restriction on types of content and whether or not there can, ethically, be restrictions on what is posted to the internet and how to deal with content posted for the greatest benefit to society.
Although some clinicians believe that maintaining online social media connections with their clients (i.e. via LinkedIn or Facebook) is helpful for the therapeutic relationship, Reamer (2013) speaks to the ethical principles that may be violated by doing this. There has to be a cooperation between the ethical issues of the
National Association of Social Workers Code of Ethics and the therapeutic relationship.
Client privacy and confidentiality are among the ethical obligations to the client that are often violated when using digital media (social media) (Reamer, 2013). There is an issue SOCIAL WORKERS’ DUTY TO REPORT DANGERS 36 when social workers are attempting to provide services over the internet, but there is another set of issues when it comes to connecting with a client on social media for therapy purposes because of the potential for dual relationships and boundary issues
(Reamer, 2013). There is a very fine line between monitoring social media for suicidality and monitoring social media for personal leisure time.
Discussion This systematic review was developed to explore the contemporary body of literature available on the topic of what are social workers’ obligations to report suicidal/homicidal behavior via social media posts. The goal of this research was to consider the whole relevant body of literature on the subject, rather than a simple sampling of literature. The review was set up by using inclusion and exclusion criteria, with sensitivity and specificity searches, in order to find pertinent research. What emerged from this review was a body of literature that focused on suicidal behaviors present on social media and/or the internet. What did not emerge from the literature was an answer to the research question. The findings did not indicate the obligations of social workers to report behaviors from social media. There was a plethora of information parsed out from the literature that helps to make inferences about obligations, but a lack of information that directly addressed the research question.
Lack of Response to Posts The first theme found in the literature focused on the lack of response to suicidal posts on social media. Many of the articles with this theme spoke to the issue of the suicidal social media user being ‘melodramatic’ or ‘having a bad day’ when there is a struggle happening within them. Also, considering that there is not a specific set of rules SOCIAL WORKERS’ DUTY TO REPORT DANGERS 37 for mental health practitioners to follow when it comes to content on social media, it would only make sense that there is a lack of response to these posts if clinicians are unclear about how to proceed. The obligation to report does not just lie with social workers, but also with the social media sites. There seems to be a lack of urgency on the part of social networking sites similar to Facebook and Twitter. Upon seeing a suicidal post, one has to report it through a special button which causes a crisis hotline number to be sent to the suicidal user. That’s it. There needs to be a faster way to report that someone is in need of help. The social media sites of Facebook, Twitter, Instagram, and
SnapChat were contacted for clarification of reporting suicidal posts; no response was given from any of the sites; even after multiple attempts. The need for response to suicidal posts does not start with social workers. It starts with the website and how they need to work with users to make crisis intervention easier to implement. By having a better response to suicidality or homicidality on social media, there may be focus on clinicians to access social media sites if intervention is starting upon ‘sign-in’. The articles included in this theme focused on specific stories of social media users who ended up taking their own lives because there was a lack of response from anyone they were crying out to. Many of the studies included in this theme looked at what the content of social media posts and how peer users respond to those. Some of the time, the content of posts were almost ambivalent in nature, may not produce the proper amount of urgency, and might not be the best way to evaluate response rates.
Lack of Professional Guidelines The second theme found in the literature explored the need for professional guidelines for reporting. Considering that the Minnesota Statute for mandated reporting does not include electronically-based media (i.e. social media) there is a greater need for SOCIAL WORKERS’ DUTY TO REPORT DANGERS 38 development of reporting standards for internet usage. It would be hard to effectively treat clients if you are unable to report anything they do whenever they are ‘plugged-in’.
With the amount of screen time per day increasing, there is a problem if the actions done in the digital world are ‘untouchable’. The virtual world is a place where people can represent themselves in their preferred way, but every move made is available for criticism which opens social media users to ridicule and exacerbation of possible mental illness symptoms. Multiple articles found have this theme mentioned and how someone should develop professional standards. The articles also lacked concrete examples of some professional guidelines which prevents a starting point from being developed.
Missed Posts The third theme found in the literature explored the reasons behind so many potentially dangerous social media posts being missed by other users. Baker and Fortune
(2008) specifically focused on the visibility and discretion of social media sites. They looked at the effect that a lack of visibility has on users and it was posited that users who visited social media sites that were not visible to broader society due to exclusivity of membership often felt more isolated rather than included in the group (Baker & Fortune,
2008). In contrast to that article, Varathan and Talib (2014) studied Twitter and how the coverage of that social network might have an effect on those that use it. For example, if there is an online suicide note, it could potentially reach the proper authorities within seconds to minutes versus hours for conventional communication methods thus creating a clearer pathway to help struggling users. Also, with the amount of people on social media sites, it can be nearly impossible to see all of your ‘friends’’ posts all the time. There is some fluidity to social media posts and if the suicidal post is not readily available in your queue of items to view then the post would go unnoticed thus propagating the issue. What SOCIAL WORKERS’ DUTY TO REPORT DANGERS 39 is the solution then? That has yet to be decided. It would most likely be to work cooperatively with all of the other themes, especially the development of professional guidelines.
Legal Issues The fourth theme found in the literature addresses the legal issues involved with electronically based media and suicidality. Cash, Thelwell, Peck, Ferrell, and Bridge
(2013) explicitly outline how social media sites provide ways to stay connected with friends and present ideas/feelings that are challenging to share in-person like suicidal thoughts. This invites a whole host of legal issues that, depending on who is asked, may infringe on First Amendment rights to free speech and expression. The issue that needs to be looked at is whether it would be legal to limit what can be put on social media purely for protection and safety of the users. Legal issues in terms of social workers failing to report suspected suicidality is another part of this theme. There is a risk of negligence for clinicians if reporting is not done which provides more evidence for the need to develop professional guidelines for reporting suicidality on social media. This theme was found to be extremely important, but was also not covered as aggressively in the literature as one would expect.
Ethical Issues The fifth and final theme found in the literature evaluates the ethical issues involved in reporting posts on social media. The main concept involved in this theme is the duty of care. Some articles briefly mentioned how reporting suicidality through an electronic medium might have ethical implications while others like Reamer (2013) provided in-depth information on the topic and the article was specifically geared toward social workers. All of the other articles within this theme spoke to ‘clinicians’ or ‘mental SOCIAL WORKERS’ DUTY TO REPORT DANGERS 40 health professionals’ and when an example is given it usually involves a psychologist rather than a social worker. Reamer (2013) references the National Association of Social
Workers (NASW) Code of Ethics multiple times since it lays out the ethical obligations of the social work profession as well as those obligations in relation to ‘The Digital Age’.
Otherwise, the legal and ethical themes often showed up together in a few of the articles most likely because they are commonly intertwined in practice. Most of the literature found tends to focus on the duty of care which is contrasted to the Reamer (2013) article mentioned above that was more comprehensive. Robinson et al (2015) also mentioned ethical issues in terms of duty of care, but also privacy and confidentiality. There are many facets to this theme that make it difficult to develop a universal and concrete answer to the research question.
This systematic review vaguely suggests what some obligations might be for social workers for reporting suicidal posts on social media, but there was a lack of concrete mandated reporter obligations, outside of ethical obligations, regarding suicidal posts on social media. Although the research in this review does not outline specific obligations for social workers as mandated reporters, it does allow for inference into what the obligations should be for clinicians and what best practices are for interactions with clients via social media.
Limitations While this research was designed to include all relevant contemporary research on the topic of social workers’ obligations for reporting suicidal and homicidal behavior on social media, there were still a number of limitations to this systematic review. First, there was very little research that directly addressed this study’s topic. There was even SOCIAL WORKERS’ DUTY TO REPORT DANGERS 41 little research regarding social media use and direct suicidal or homicidal threats.
Multiple editorials focused on social media use and suicidal/homicidal behavior as cause of an internet user’s death. Considering that social media has only been used aggressively in the last ten years, research has only recently become a topic of exploration. The lack of a larger body of research is one of the major limitations of this systematic review.
This review was not limited to articles and research that were peer-reviewed allowing for gray literature, literature that has not been formally published in most cases, to be used. All articles were written in English which prevented a larger body of research from being used because of the English translation not being available. The use of gray literature allowed for more personal and informal narrative to be included. This helped to get a wider variety of relevant literature, but also caused a lacked the exclusivity of using only peer-reviewed articles of other systematic reviews. Literature that was included focused on suicidal behavior on social media, excluding suicidal ideation because social workers do not report based on that idea alone.
This systematic review focused on guidelines for social workers when reporting issues on social media, but there is a lack of state and federal guidelines. This posed a challenge for research evaluation because there was a lack of concrete ‘rules’ for how to report. The only information that could only be inferred was based on what was suggested or vaguely referenced to in state statutes. Also, procedures specifically outlined for social workers were not found during research. Most procedural literature was geared toward psychologists and offered very little information directed at social workers regarding mandated reporting. SOCIAL WORKERS’ DUTY TO REPORT DANGERS 42
Further Research and Implications The first issue to emerge from this systematic review was how limited the research is regarding social worker’s obligations for reporting suicidal and homicidal messages on social media. Mandated reporting guidelines are more commonly focused on issues of child abuse and neglect than anything else, including social media use. While the concept of mandated reporting is widely known, the challenges arises when considering how to report issues on social media and/or the internet. It is necessary to conduct research that specifically focuses on what social workers’ views on their obligations for reporting problems on social media are. Since there is such a lack of research, it would be most helpful to perform qualitative interviews to address themes of clinicians that are dealing with this issue first hand. The ‘what’ and ‘how’ would be addressed through qualitative research better than a systematic review because of the narrative and personal nature of the interviews.
A systematic review on this topic is important to social work because it may help to develop statutes to guide clinicians in their practice with clients. This would work to enhance best practices for social workers and guide treatment in order to prevent social media users from committing suicidal or homicidal acts. By creating best practices for clinicians, it would allow formal training to be developed in order to learn how to address suicidal and/or homicidal issues without meeting face-to-face with the client.
As much as the development of concrete standards would be most helpful for clinicians working with clients who have a social media presence, it would also be beneficial for lay persons to know what signs to watch for on social media. If there are social media users that would be able to notice problem situations (similarly to a ‘good SOCIAL WORKERS’ DUTY TO REPORT DANGERS 43
Samaritan’) and react accordingly, then it would be easier to help those in need. This study may affect mezzo and micro practice, but also has implications for macro social work. If statutes that affect the profession of social work are developed in order to best treat clients with suicidal or homicidal social media posts, then society as a whole could benefit.
Currently, in the mental health field, suicidal and/or homicidal posts on social media are not referenced in state or federal statutes regarding mandated reporting.
However, given the increasing presence of social media in the treatment of clients, it is important to include internet use in mandated reporting guidelines for social workers. As more research continues to be conducted on suicide, social media use, and social workers’ obligations, there will need to be a shift in how treatment is provided and issues are detected.
SOCIAL WORKERS’ DUTY TO REPORT DANGERS 44
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Appendix A: Included Articles and Summary Database Title Author(s) Summary
Academic “Girl’s suicide Alvarez, L. News article that focuses on a Search points to rise in (2013) case of an adolescent that was Premier apps used by terrorized of social media by cyberbullies.” peers with a new cell phone app. The girl posted numerous times on various social media platforms and was antagonized to complete suicide; she ended up completing suicide.
“Suicide and the Biddle, L., Performed web search and Internet.” Donovan, J., analyzed which type of website Hawton, K., & came up first. Challenges Kapur, N. (2008) involved with suicide’s presence on social media/the internet were discussed. Often times suicidal people are encouraged on social media to complete suicide and there is little to no outside action taken to prevent this.
EBSCO “Facebook International News article that discusses the MegaFile suicide Business Times various suicide preventions prevention (2011) techniques of social media sites. service: Help for Most of them include emailing users or invasion potentially suicidal user phone of privacy?” numbers and information; very little direct contact. Many examples are given that outline social media user’s suicidal posts were unnoticed, not reported, and the people ended their own lives.
“Questions about Hussey, K., & A student continuously posted missed signs after Leland, J. (2013) suicidal messages via social 15-year-old boy’s media and they were consistently missed by family SOCIAL WORKERS’ DUTY TO REPORT DANGERS 51
suicide in and school officials. Even Greenwich.” photos of the person with a knife to his throat and there was not any action until he was found dead. All the signs, except the overt depression, was missed via social media.
“US woman, International News article regarding a Cynthia Lee, Business Times woman who posted a suicide posts disturbing (2012) note via Facebook. Posts were suicide note on not seen and woman killed Facebook.” herself hours after sending suicidal messages on social media.
Google “Cybersuicide: Alao, A.O., Nine cases of Scholar Review of the Soderberg, M., attempted/completed suicide in (Gray role of internet on Pohl, E. & Alao, which the person searched Literature) suicide.” A.L. (2006) suicide information on the internet. The outcome of each case was covered including the response of other people using social media.
“Responses to a Fu, K., Cheng, A quantitative content analysis self-presented Q., Wong, P., & of microblogs and the suicide attempt in Yip, P. (2013) discussions had on them. social media.” Diffusion of messages was discussed and how the initial suicidal messages can be used as a tool for a ‘rescuing platform’ in order to engaged isolated individuals. Identifies ways clinicians can be helpful to clients surrounding their social media use.
“Suicide Ruder, T.D. Case study that focuses on a announcement on Hatch, G.M., client who posted a suicidal Facebook.” Ampanozi, G., message on Facebook and the Thali, M.J., & post was noticed, but not fast SOCIAL WORKERS’ DUTY TO REPORT DANGERS 52
Fischer, N. enough. Struggle for (2011) professional literature to discuss protocols associated with social media and suicidality/homicidality.
“Suicide Varathan, K.D., A pilot program that would detection system & Talib, N. detect suicidal posts on Twitter based on (2014) is outlined. The struggle of Twitter.” other social media users not seeing suicidal posts and alerting the police is reviewed, as well as the lack of a concrete action plan for actively suicidal individuals on social media.
“Suicide and Robinson, J., A systematic review that social media.” Rodrigues, M., searched through databases for Fisher, S., & articles that related to suicidal Herman, H. behavior (including completed (2014) suicide) and social media use. It was found that social media was not used to seek professional help but to share experiences and “cry for help”.
“The internet and Tam, J., Tang, Suicide as a public health suicide: A W.S., & problem and how there is a lack double-edged Fernando, D.J.S. of media guidelines for tool.” (2007) clinicians who may encounter social media/internet information from clients. Using the internet as a helpful tool is also discussed briefly.
PsycInfo “Adolescent Cash, S. J., MySpace posts were analyzed suicide Thelwall, M., for suicidal content. Of 1000 statements on Peck, S. N., posts found, 50 percent MySpace.” Ferrell, J. Z., & referenced “kill myself” or Bridge, J. A. “suicide” in them. Results (2013) indicated that users may use social media for seeking help SOCIAL WORKERS’ DUTY TO REPORT DANGERS 53
sometimes, but identifying at risk social media users remains a challenge for clinicians.
“Ethical Lehavot, K., Ethical issues surrounding considerations Ben-Zeev, D., & social media and and social media: Neville, R. E. suicidal/homicidal clients are A case of suicidal (2012) discussed. Specifically, postings on beneficence and maleficence Facebook.” regarding clinicians being alerted to suicidal/homicidal behaviors on social media and the potential for negligence if there is an adverse outcome. Clinicians are urged to consider their legal responsibility when they encounter client information on a social media platform.
“Similarities and Belfort, E.L., Content analysis of ER differences Mezzacappa, E., psychiatric assessments over 4- among & Ginnis, K. year period. The number of adolescents who (2012) suicidality posts increased over communicate the 4-year period and a peer suicidality to may be the ‘first recipient’ of others via the distress call. The need for electronic versus timely helpful provisions is other means: A great and can largely affect pilot study.” clinical management of the distressed individuals.
“Social media Robinson, J., Systematic review that searches and suicide Cox, G., Bailey, databases (Medline, PsycInfo, prevention: a E., Hetrick, S., Embase, CINHAL & Cochrane systematic Rodrigues, M., Library) for articles that focus review.” Fisher, S., & on suicide-related behavior and Herman, H. social media. Challenges (2015) resulting from this include controlling risky behavior and SOCIAL WORKERS’ DUTY TO REPORT DANGERS 54
appropriately assessing for risk over the internet.
“Suicide on Ahuja, A.K., Case discussion surrounding the Facebook.” Biesaga, K., announcement of a suicide Sudak, D.M., attempt via email and Facebook Draper, J., & post. Using social media to Womble, A. identify where users are when (2014) they post suicidal messages by using internet data and GPS. Thought to be an idea for helping quickly identify those who are struggling. Discussion around a current lack of response was outline as well.
“The Westerlund, M., An exploratory design study representation of Hadlaczky, G., where search engine results suicide on the & Wasserman, were analyzed and compared. internet: D. (2012) Challenges for clinicians Implications for regarding encountering pro- clinicians.” suicide or general suicidal messages on social media. Dialogue between clients and clinicians need to happen; not just unidirectional information or helpline numbers.
“Understanding Baker, D., & A qualitative study of young self-harm and Fortune, S. adult website users. Interviews suicide websites.” (2008) were regarding self-harm and suicide websites and the potential uses for them. Results revealed that some users spoke of social media suicide sites as communities. Discussion surrounding clinicians can help clients if they ask for help via the internet, as well as how social media suicide websites isolate people further thus SOCIAL WORKERS’ DUTY TO REPORT DANGERS 55
perpetuating suicidal issues in users.
SocIndex w/ “Duty to warn, Granich, S. Outlines the Tarasoff Case of Full Text duty to protect.” (2012) 1974. Relates Duty to Protect and Duty to Warn to clinicians working with suicidal/homicidal clients.
“Social media Luxton, I. D., Ethical and legal issues and suicide: A June, J. D., & regarding social media and public health Fairall, J. M. clinicians are discussed. perspective.” (2012) Internet is less regulated and there are few restrictions on content. Double-edged sword of protecting clients from harm and/or violating their privacy.
“The Zdanow, C., & Study using thematic content representation of Wright, B. analysis of social media users’ self-injury and (2012) statements. Normalism, suicide on emo Nihilism, Glorification, ‘Us vs. social networking Them’, Acceptance, Reason, groups.” and Mockery were the identified themes. Results indicated that many often antagonize suicidal people on social media and little is done to try and protect them.
Articles “Making the Krase, K.S. Covers the basics of mandated Found Tough Call: (2013). reporting: what should and Through Social Workers should not be reported and Other as Mandated when. Focuses on what should Means Reporters.” be reported on when outside professional role.
“Pro Self-Harm Boyd, D., Ryan, In depth description of pro-self- and the Visibility J., Leavitt, A. harm and pro-suicide websites of Youth- (2010). and how visibility of those Generated websites can harm social media users. It also outlines how SOCIAL WORKERS’ DUTY TO REPORT DANGERS 56
Problematic efforts by practitioners are Content.” lacking when it comes to helping people who encounter these websites.
“Social Work in a Reamer, F.G. General ethics of social workers Digital Age: (2013). is discussed. A further focus on Ethical and Risk how social workers should act Management ethically when it comes to Challenges.” technology/social media and helping clients as they use it.
“Tarasoff and the Appelbaum, P.S. Tarasoff case and Duty to Clinician: (1985). Protect/Duty to Warn concepts Problems in are discussed. As well as the Fulfilling the confusion of therapists as to Duty to Protect.” what their obligations are to report situations of violence and/or suicide.
“The Antisocial Dickey, J. TIME Magazine article that Network.” (2014) focuses on a kid who posted suicidal messages on social media numerous times and there was not anything done with them. Kid ended up completing suicide. Suggestions for preventing this from happening again are explored.